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HomeMy WebLinkAboutBLDG-22-001328 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'k." CITY YARMOUTH MA DATE September 07,202 PERMIT# BLDG 22-001328 li� JOBSITE ADDRESS 24 KATES PATH VILLAGE OWNER'S NAME Roger Deromondi G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS—> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT , TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER , OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT - I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Eric Whiteley LICENSE# 115920 I SIGNATURE MP© MGF 0 JP 0 JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: IERIC T WHITELEY I ADDRESS. Po Box 248, CITY (West Chatham (STATE MA ZIP 026690248 TEL FAX 1 I CELL I I EMAIL 1 I S310N M3IA3?J NVId #1101213d $:333 ❑ ❑ 111n1213d 3H1 SY S3AH3S NOI1VOIlddV SIH1 ON SOA S310N N01103dSNI 1VNld AINO 3Sf1 N0103dSNl 210d 30Vd SIHI S310N N01103dSNl SVO H0f108 Job: Cost: S I . \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t•w `�=.-coin= PERMIT# : kip CITY Yarmouth MA DATE j 09/03121 _ -CZ— 13 7_ JOBSITE ADDRESS: 24 Kates Path OWNER'S NAME Deromedi GOWNER ADDRESS [900 East Illonois Rd,Lake Forest, IL 60045 TEL 8479178185 1FAX[ PR I)°R OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT:H PLANS SUBMITTED: YES NO1 i' APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ BOOSTER ._ ____ ' CONVERSION BURNER _ __ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR,r 4 FURNACE 1 GENERATOR GRILLE _._-$._. INFRARED HEATER .2 LABORATORY COCKS MAKEUP AIR UNIT _3 _OVEN 7 POOL HEATER 3 —ROOM 1 SPACE HEATER ROOF TOP UNIT V1 TEST UNIT HEATER 7. UNVENTED ROOM HEATER 1 WATER HEATER L OTHER Lk' INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑x NO ❑ ( I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY x❑ OTHER TYPE INDEMNITY ❑ BOND ❑ � OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ t}1 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianro with all PPrtinpntt,rrwiicion of the �( Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A)�I�""�_ PLUMBER-GASFITTER NAME Eric T VVhiteley LICENSE# 15920 SIGNATURE MP❑x MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION ❑x # 3489 PARTNERSHIP❑# LLC❑# COMPANY NAME: W Vernon Whiteley,Inc. ADDRESS 28 Village Landing,PO Box 1266 CITY West Chatham STATE MA ZIP 02669 TEL (508)945-1100 FAX (508)945-5549 CELL EMAIL ehiteley@wvwhiteley.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES